Unifying Nurses with Frontline Workers to Promote Equity

Disparities highlighted throughout the COVID-19 pandemic illustrated the need for a collaborative movement among nurses and frontline workers who maintained society throughout the crisis. To support and retain the healthcare workforce and improve the health of communities, nurses and their fellow frontline workers, as experts in their communities and end users of their policies, must collaborate in seeking pathways toward a more impactful role in policy development and decision-making. The most effective means of implementing lessons from the COVID-19 pandemic and elevating the voices of the workforces that led the way through it is to bring those voices together in advocacy. This article outlines multidisciplinary theoretical frameworks that could bolster a collaborative movement towards equity while exploring example initiatives, current efforts, and the barriers between frontline workers and the equitable distribution of their services.

COVID-19 Disparities

Throughout the COVID-19 pandemic’s many phases, frontline nurses persevered in striving to meet the health needs of their communities– from working during the initial lockdowns despite inconsistent access to necessary supplies, including Personal Protective Equipment (Bhaksar et al., 2020) to weathering the ebbs and flows of each variant, to supporting a national vaccination effort of unprecedented scale in recent history (Tatar & Wilson, 2021). However, despite the devoted and admirable efforts of nurses, their fellow healthcare colleagues, and frontline workers in general, inequities in healthcare, education, and global and U.S. societies were laid bare (Bhaksar et al., 2020). Communities of color and other underserved populations experienced disproportionately higher rates of infection, hospitalization, and mortality secondary to COVID-19 and related sequelae (Ndugga et al., 2023; Presidential COVID-19 Health Equity Task Force, 2021; Xu et al., 2021). In New York City (NYC), the highest number of COVID-19 cases were often concentrated in lower-income neighborhoods in parts of Brooklyn, Queens, and the Bronx, resulting in the death of Black and Latino New Yorkers at twice the rate of White New Yorkers during the early phases of the pandemic (Mays & Newman, 2020; New York City Department of Health and Mental Hygiene, 2020). These inequities touched every facet of life, and the same racial, ethnic, and socioeconomic groups that were most impacted by the virus were also facing barriers to education in an environment where internet access and computers equipped with cameras had suddenly become a prerequisite to attending school (Irwin, 2021).

The pandemic highlighted and exacerbated pre-existing fault lines in our nation’s public services network (Bhaksar et al., 2020; Moore et al., 2022; NAACP, 2020; Presidential COVID-19 Health Equity Task Force, 2021). No groups are better equipped to develop and lead solutions to these disparities than the nurses and frontline workers striving to overcome them daily. The pursuit of health equity, defined by the Centers for Disease Control and Prevention (CDC) as “the state in which everyone has a fair and just opportunity to attain their highest level of health,” is inherently intertwined with the pursuit of justice in other areas of life such as housing, employment, and education (CDC, 2022). Because of this, a nurse’s pursuit of equity is naturally connected to the work of others in public service.

The Voices of the Frontlines

Throughout the pandemic, nurses and their fellow frontline workers were reminded of their vital role in society. Yet, their lack of voice in policy and decision-making was also underscored as the pandemic wore on. Nursing professionals suddenly found themselves among a class of workers deemed “essential” but left feeling powerless in pursuing equitable solutions to the crises at hand. Consider, for example, that no nurses were represented among the 28 members of the Trump Administration’s White House Coronavirus Task Force. In comparison, President Biden’s COVID-19 Health Equity Task Force (12 members) contained one nurse who was also the president of her nurses’ union (Dermenchyan & Choi, 2020; Presidential COVID-19 Health Equity Task Force, 2021). Increasing the voice of the nursing workforce through collaborative leadership and advocacy could ameliorate many of the struggles facing the profession today while also empowering these frontline workers to address the needs facing their patient populations and communities, especially in times of crisis.

The work of the Presidential COVID-19 Health Equity Task Force and their Final Report and Recommendations (2021) serve as motivation for the proposals raised in this article. The group aptly articulated the need for change when they wrote,

“Race, ethnicity, geography, income, ability, sexual orientation, gender and gender identity, immigration status, and other identities, either alone or in combination, should never stand in the way of equitable health. Unfortunately, this is a part of our nation’s past and present. Health inequities did not begin with the COVID-19 pandemic, but we now have an opportunity to disrupt patterns of harm, offer course correction, and transform inequitable systems, structures, practices, and processes. Health justice for all requires removing systematic limitations, promoting genuine partnerships across sectors, and establishing trustworthiness of public and private institutions responsible for supporting the well-being of all individuals and communities.” (p. 19)

Advancing Health Equity for the Good of Society and the Profession

First, nurses seek to advance equity because it is core to their role definition and duties. For many, advancing equity through nursing is also a calling. The first provision of the American Nurses Association’s Code of Ethics states, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA, 2015 p. v), and ANA President Earnest J. Grant once asserted that the code of ethics, “obligates nurses to be allies and to advocate and speak up against racism, discrimination, and injustice” (ANA, 2020).

Because nurses are committed to caring for their patients equitably, barriers to doing so can cause great moral distress. A meta-synthesis analyzing compassion fatigue in nurses found that stress related to prolonged professional workload, feelings of a lack of support, and difficulty carrying out the job as desired all contributed to burnout (Nolte et al., 2017). Burnout is costly, increasing gaps in care delivery and further exacerbating strains on the healthcare system. According to the National Council of State Boards of Nursing, approximately 100,000 Registered Nurses have left the workforce during the COVID-19 pandemic due to stress, burnout, and retirement (Martin et al., 2023). Seeking improved avenues to alleviate disparities in healthcare is vital, not only for patients and communities but also for the mental health, longevity, and retention of nurses and the healthcare workforce.

Applying Multidisciplinary Theories to Drive an Interdisciplinary Movement

Four key frameworks could motivate and inform a collaborative interdisciplinary movement toward equity. These include Social Determinants of Health, Health in All Policies, Street-level Bureaucrats, and Accumulation by Dispossession. Each theoretical framework is defined, and example initiatives are proposed that illustrate the utility of that framework for the movement. While the term ‘frontline worker’ encompasses a variety of distinct working groups, each group has a role to play in advancing equity in U.S. and global society. Analyzing theoretical frameworks from multiple disciplines could connect the groups and drive future collaborative movements to alleviate societal disparities.

Social Determinants of Health

Social Determinants of Health (SDOH) are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (Office of Disease Prevention and Health Promotion [ODPHP], n.d.). These determinants of health can be summarized in five broad categories: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. These determinants of health explain why patient education and provision of care alone cannot eliminate health disparities. The many facets of an individual’s life interact to affect their overall health. When inequities exist in any of these domains, that person's health is impacted. For instance, during the COVID-19 pandemic, individuals with lower incomes, higher household occupancy, or lower health literacy, resulting in decreased ability to practice social distancing in their homes or at work, faced higher exposure to the COVID-19 virus (Nous, 2020). AUTHOR: This reference no longer exists, is there a replacement we can add? These individuals' economic status, built environments, and community contexts negatively impacted their health. That is why one of Healthy People 2030’s five overarching goals addresses SDOH. That goal is to “create social, physical, and economic environments that promote attaining the full potential for health and well-being for all” (ODPHP, n.d.).

Using Social Determinants of Health as a Call to Action-Exemplars

SDOH can serve as a roadmap for areas where advocacy is needed and a unifier for the varied groups of frontline workers seeking to alleviate health disparities. Initiatives like Healthy People 2030 that focus on SDOH encourage cross-sector collaboration among those working to promote individual, population, or community wellness. It can also foster the exchange of professional knowledge and collaborative efforts by acknowledging how other fields impact the goals of each public service industry.

School Nurses. One area of nursing that poses an excellent opportunity for interprofessional impact on an individual or community’s SDOH is school nursing. The health and education of children are intertwined such that healthy children perform better in school and educated children experience improved health outcomes (Johnson, 2017). Students who have access to the services of a school nurse have improved attendance (Johnson, 2017). School nurses stand at the intersection of health and education to advocate for their students’ advancement. School nurses are uniquely positioned to bridge gaps, promote change, and partner with the school system, educators, children, and parents because they are healthcare professionals in the educational setting (Bullard et al., 2021). School nurses can promote equitable health and education outcomes through their work with sexual health education and the services they provide to children with disabilities and chronic health needs. School nurses are improving SDOH in impactful ways in their everyday work. However, the availability of their services is being threatened by inconsistent funding (Johnson, 2017). Healthcare leaders and advocates must partner to protect this critical service and foster channels to uplift the voices of those working in this vital specialty.

Interprofessional, Team-based Partnership. Healthcare settings across the U.S. have implemented the SDOH framework to identify and address multidisciplinary patient needs. One published example comes from Rush University Medical Center (RUMC), where the hospital has deployed a team-based partnership model through an SDOH screening tool (Williams et al., 2018). This seven-item tool has been implemented in the Emergency Department and primary care clinics, and results from the tool can be used to inform further screening assessments of patient social needs. In this pilot program, nurses at RUMC screen inpatients for housing, utility, transportation needs, food security, and health insurance status. Based on identified needs, follow-up interventions are executed through collaboration across departments internally and with outside agencies. This model encourages collaboration among clinical and non-clinical personnel, including nurses, social workers, case managers, and food service workers, to improve patients’ SDOH (Williams et al., 2018). Similar tools are utilized widely across various healthcare settings in the U.S. today. Nurse navigators and non-clinical patient navigators are two roles often employed to implement the SDOH framework to assess and address ancillary patient needs impacting health outcomes in inpatient and outpatient care areas. Examining the social needs of patients encourages staff to seek holistic solutions in collaboration with professionals in fields outside their own. While screening tools and collaborative networks are essential in improving patient SDOH, it can be difficult for patients to share these needs and for nurses to assess them and speak about them effectively. Education initiatives among the public and nurses in the field are required to ensure that this tool is appropriately implemented in various settings (National Academy of Sciences, Engineering, and Medicine [NASEM], 2021).

Union Collaboration. Another way to improve SDOH across multiple frontline fields is through union collaboration. A partnership between the National Federation of Nurses (NFN) and the American Federation of Teachers (AFT) is a strong example. The two groups began collaborating and found the partnership so propitious that they merged in 2013, bringing 34,000 nurses into the AFT union’s 1.5 million members (Rosenberg, 2013). The president of NFN predicted that the collaboration would enhance bedside nurses’ professional influence through collective bargaining during a momentous change in healthcare policy (Rosenberg, 2013). This partnership is an excellent model of how interprofessional collaboration can advance working conditions within each field and for the recipients of the field’s services. Unions can use their shared goal of promoting equity and improving SDOH among their members and communities to encourage collaboration with other unions. The partnership was so successful that in 2018, NFN agreed to formally dissolve and remain a permanent component of the AFT union (Huntington, 2018). The joint union continues working together to advocate for nurses and teachers and their patients, students, and communities today.

One lesson from this partnership is that effective collaboration can begin within existing efforts and institutions. The AFT and NFN had already been working separately to amass political capital and unite the workers in their fields. Rather than starting a new union or recreating this work, the two groups combined efforts to increase their impact. The conditions experienced by healthcare workers during the COVID-19 pandemic have elicited an increased interest in labor organizing and unionization (Abrams, 2021; Philbrick & Abelson, 2021). These unions could focus on how the SDOH impacts their members and their communities to encourage collaboration with other unions and inform necessary change.

Health in All Policies

Another popular and related set of ideas that could serve to unify and empower nurses and other frontline workers is the Health in All Policies (HiAP) approach (American Public Health Association [APHA], 2013; Association of State and Territorial Health Officials [ASTHO], n.d.; Williams et al., 2018). The HiAP approach acknowledges that health problems cannot be solved by the health sector alone and calls for incorporating health considerations into all policy areas. While HiAP’s roots date back to nineteenth-century public health pioneers, the World Health Organization’s (WHO) (2014) Helsinki Statement on Health in All Policies formally reintroduced the term on the global stage, reaffirming health equity as a core responsibility of governments. The concept has since continued to gain momentum globally, integrating into cross-disciplinary policy worldwide. The HiAP approach is endorsed by the CDC and U.S. Departments of Health at federal and local levels. It can be found as a driving force behind many U.S. policies, such as the Affordable Care Act’s National Prevention Strategy, the work of the Presidential COVID-19 Health Equity Task Force, and countless state and local initiatives (CDC, 2016; Presidential COVID-19 Health Equity Task Force, 2021; Siegel, 2023). Key components of HiAP include cross-sector collaboration, defining mutually beneficial goals, engaging stakeholders, creating opportunities for policy change, and promoting health and equity. The HiAP approach encourages information exchange, invites participation, elicits collaboration, and engages stakeholders to empower interdisciplinary solutions to advance equity (ASTHO, n.d.). Implementation of HiAP in various policy-making bodies might encourage the inclusion of nurses in more interdisciplinary initiatives, allowing the nursing lens to be applied and the voices of nurses to be heard in all policy areas.

HiAP In Action

HiAP Task Force in Chicago. Various federal and local policies and initiatives have widely implemented this strategy. One example is the City of Chicago’s 2017 HiAP Task Force, implemented as a part of their Health Chicago 2.0 initiative (Williams et al., 2018; Chicago Department of Health, 2017). The task force included representatives from 24 City of Chicago Departments and seven sister agencies working to establish a HiAP approach to city decision-making. The task force published 16 recommendations designed to implement the framework in every area of the city’s government. While the execution of these recommendations is heavily dependent on funding, this task force is a great model for how city governments can bring together various departments and inspire cross-sector collaboration to impact health equity.

Local Health Departments Combating Lead Poisoning. Another strong example of the utility of the HiAP approach is a case where three local health departments were awarded funding to advance efforts to reduce lead exposure using a HiAP approach. The CDC’s National Center awarded the grant for Environmental Health, the National Center for Healthy Housing, the National Association of County and City Health Officials, and the Agency for Toxic Substances and Disease Registry, and represents the government’s belief and willingness to invest in the concept (Siegel, 2023). One participating department reported that the HiAP approach facilitated the dissolution of communication barriers between teams, enhanced the identification of progress, and fostered a shared narrative used to document the team’s successes. A limitation of the HiAP strategy was that it is time-intensive to communicate and balance the various strategies presented by this interdisciplinary approach (Siegel, 2023). Nurses seeking to advance equity and represent the profession through interdisciplinary leadership and collaboration should consider implementing a HiAP framework to support their work.

Street-level Bureaucrats

Another key theoretical framework underpinning the idea that frontline workers have the potential to advance equity and address the disparities highlighted throughout the COVID-19 pandemic is Michael Lipsky’s sociological theory of Street-level bureaucracy (Lipsky, 1980; 2010). Lipsky’s book, Street-level Bureaucracy: Dilemmas of the Individual in Public Services, published initially in 1980 and later expanded in a 30^th-anniversary version in 2010, highlights the critical role that public service workers play as implementers of policy with broad discretionary powers in their day-to-day work. Lipsky describes street-level bureaucracies as the places where citizens directly experience the government and street-level bureaucrats such as teachers, social workers, guidance counselors, judges, lawyers, nurses, doctors, police officers, and other workers who regularly interact with the public as a critical role in the chain of policy at its endpoint: its execution. His analysis aptly explains how these workers are often thwarted from performing to their highest standard because of a lack of time, information, and other necessary resources (Lipsky, 2010). While Lipsky’s theory was initially written in 1980, his descriptions of the barriers facing public service workers such as nurses and other frontline workers ring true today. Barriers to equitable distribution of services have led to a twin crisis of disparities in health, housing, wealth, and education (to name a few), and workforces experiencing significant burnout, leading to staffing shortages (Martin et al., 2023). His theory explains the current state of health among nurses and other frontline workers and empowers these groups to elicit change as policy actors.

Distinctions Among Public Service Workers. One important caveat in Lipsky’s theory that must also be applied to the collaborative work proposed in this article is that while the theory of street-level bureaucracy may pull together these disparate groups of workers and professions to identify shared central tendencies and potential barriers to their efforts, it is also vital to acknowledge the differences among the groups- their norms, values, experiences, professionalization, and goals (Lipsky, 2010). As a seminal work in public policy, Lipsky’s framework has been written about extensively and applied to various industries across countless historical, cultural, and geographic contexts (Chang & Brewer, 2022; Cooper et al., 2015; Dickson & Brindis, 2021; Hughes & Condon, 2016; Lipsky, 2010). Conclusions drawn about the nursing workforce may not apply to other frontline workforces. Further exploration of shared goals among the groups would be an important first step in bringing them together in advocacy to work toward equity. Despite varying demographic, leadership, and educational compositions, the individuals serving American communities all share a commitment to doing so equitably.

While unique roles, functions, and connections to the theory exist between the many service industries described, distinctions also exist within each workforce. Although most areas of nursing include some form of care for the public, the applications of this theory may be more pertinent to some healthcare entities and nursing specialties than others. Two areas of nursing that strongly exemplify Lipsky’s definition of street-level bureaucrats include public health nurses and school nurses. While the value of school nursing was discussed previously, public health nurses also play a vital role in enacting policy day-to-day and impacting their communities’ determinants of health. Another valuable role with which nurses and nurse advocates could seek to partner is that of community health workers. While community health workers do not include formally trained medical or healthcare professionals, they are community advocates and agents of social change that could provide vital partnerships for nurses seeking to deliver equitable healthcare and enact equitable health policy (APHA, 2022).

This theory usefully frames the workers that came to be known as the frontlines of the COVID-19 pandemic as the frontlines of government itself. In conceptualizing nurses and fellow frontline COVID-19 responders as street-level bureaucrats, we empower these groups to wield their discretionary authority and expertise toward alleviating the disparities exacerbated by the pandemic. This theory acknowledges the power inherent in groups of workers who act as the end-users of public policy in their day-to-day work. Harnessing this power to connect the fields in advocacy efforts could be the key to unlocking more equitable public service distribution and alleviating racial, ethnic, and socioeconomic disparities in the U.S.

Accumulation by Dispossession

One framework nurses can explore when fostering interprofessional collaboration is accumulation by dispossession. The term ‘accumulation by dispossession,’ coined by David Harvey in his book, The ‘New’ Imperialism: Accumulation by dispossession, amends the theory of primitive accumulation, wherein capital is gained by those in power through the displacement and/or dispossession of Indigenous and less ‘powerful’ groups, to place it in a more modern context (2009). Harvey’s theory suggests that subordinate working classes are often disenfranchised by various predatory policies and practices as the leaders and entities that employ them pursue profit.

Examples
The Occupy-Labor Movement. The Occupy movement was an international socio-political movement that began in 2011 and expressed opposition to economic inequality. One study examining the role that this concept of accumulation by dispossession may have played in the 2011 Occupy Labor Movement in Chicago concluded that the dispossession of these groups of workers by entities seeking to increasingly accumulate capital among a narrow group of leaders and stakeholders in the United States (U.S.) was a motivating factor for such a significant social movement spanning multiple industries and political groups (Collins, 2012). In Chicago specifically, the participation of labor activists and unions in the early stages of Occupy Chicago helped foster the pro-labor orientation of the movement. National Nurses United set up First-Aid tents in the encampments, leading to the arrest of some nurses (Dirr, 2012). On Wall Street in NYC, the United Federation of Teachers, the National Nurses United, and the Service Employees International Union were all present, the latter providing a volunteer force of Registered Nurses (Gould-Wartofsky, 2015). This movement had many faces and localities, but it provides a recent example of interprofessional collaboration among several labor and political groups, including a few of those that would later become the frontline workers of the COVID-19 pandemic (Collins, 2012; Dirr, 2012; Gould-Wartofsky, 2015). Collins’ work suggests that interprofessional movements can be motivated by a unified opposition to accumulation by dispossession. She also argues that this understanding implies a need for unity among labor groups and those more broadly involved in caring or providing services for others– such as frontline workers.

Disenfranchisement Among Female-Dominated Professions. Another study, which does not cite this theory by name but touches on a similar concept, examines bedside nurses and elementary French teachers to demonstrate similarities in their marginalization, attitudes, discretionary power, and locus of control (Daiski & Richard, 2007). The study concluded that women and men in these ‘feminized’ fields experience oppression and often internalize devaluation of their worth, leading to further disempowerment of the groups. The study suggests that recognizing this dispossession is essential to improving their conditions as a marginalized group of working professionals (Daiski & Richard, 2007). While the various industries comprising the frontline workforce possess distinct levels of autonomy and influence and different demographic and gender identity composition, it is worth considering that the teaching and nursing workforces in the U.S. remain predominantly composed of women and may be subject to disenfranchisement because of cultural norms regarding gender. For example, in 2018, women comprised 89% of public elementary school teachers and 60% of public high school teachers in the U.S. Yet, the average base teaching salary of female full-time public school teachers remains less than that of their male counterparts at $55,490 annually compared to $57,453 (Merlin, 2022; Institute of Education Science, 2020). Globally, it is estimated that women comprise 70% of health workers, yet only 25% of global health organizations have gender parity at senior management levels and 20% among their governing bodies (Betron et al., 2019).

These examples of dispossession among some of the frontline workgroups could motivate their unified efforts to pursue equity within their ranks and, eventually, in their delivery of services. Publishing work that discusses these issues and encouraging interdisciplinary solutions could be instrumental in amassing enough support to pave the path toward a more just and equitable society.

Recommendations for practice

The evidence presented in this article suggests that nurses seeking to impact their communities positively and equitably serve their patients through their work could best meet these goals by collaborating with their fellow frontline workers and leveraging lessons from the COVID-19 pandemic to advance equity. Recommendations for nursing, advocacy, and leadership practice include:

1. Seek interdisciplinary collaboration among frontline workers both within the healthcare setting and outside of it.

2. Develop interdisciplinary leadership groups in government, public health, and healthcare leadership settings and seek nurse representation in such groups.

3. Foster collaboration among unions representing frontline fields.

4. Support and invest in areas of nursing that function in interdisciplinary spaces, such as public health nursing and school nursing.

5. Apply the SDOH lens and HiAP approach to care delivery, advocacy, and policy development.

6. Continue to educate the public and the healthcare workforce about health disparities, SDOH, and HiAP to encourage innovative solutions to health disparities.

7. Continue research and academic inquiry regarding the role of nursing in interdisciplinary leadership, health equity, policy-making, and advocacy.

Conclusion

The multidisciplinary theories serve as guiding structures and explanatory frameworks to light a path forward from the pandemic. Exciting work is already being led by nurses seeking to utilize lessons from the COVID-19 pandemic to advocate for more equitable care delivery. The implementation of initiatives driven by SDOH and HiAP represents exciting paths forward. Exploring Lipsky’s theory of Street-level bureaucrats and Harvey’s theory of Accumulation by Dispossession allows us to apply an interdisciplinary lens as we pursue interdisciplinary solutions to health equity.

A crucial factor to consider when pursuing this work is the variations in characteristics and beliefs among the many people groups comprising the frontline workforce. These frameworks may not resonate with all segments of frontline workers. However, they could serve as uniting ideologies and a theoretical space where multiple industries coalesce. Further research exploring the individuals and industries comprising public service's frontlines and their relationships with the theories summarized above is warranted.

Nurses strive for health equity because it is both their duty and calling to provide quality services to every patient. Nurses are natural advocates, working to improve their patients' and communities' health and well-being. The inability to deliver care equitably contributes to nurse burnout and moral fatigue. Identifying means of increasing health equity will benefit nurses as individuals and as an integral component of the healthcare workforce. COVID-19 exacerbated and highlighted inequities existent in U.S. and global societies. Overcoming the significant barriers to a more just and equitable society will require collaboration and innovation across every field of public service work.

Author

Kelsey Maguire Torres, MS-MSUPL, RN, PCCN
Email: kelseynmaguire@gmail.com
ORCID ID: 0000-0002-2539-6174

Kelsey Maguire Torres, MS-MSUPL, RN, PCCN has practiced as a Registered Nurse for over ten years. She participated in Memorial Sloan Kettering Cancer Center’s Nursing Research Fellowship in 2018 and received the Outstanding Alumni Award from Belmont University’s School of Nursing in 2022. She graduated from City University of New York (CUNY)- Hunter College’s dual master’s program in nursing administration and urban policy and leadership in 2023. This piece was written under the mentorship of her professor in the program, Dr. Catherine Voulgarides, Ph.D. Kelsey’s experiences as a nurse in New York City during the COVID-19 pandemic, along with her studies in nursing and urban policy, have led to a passion for work applying the nursing lens to the pursuit of health equity, particularly in the urban setting.